What is the recommended inpatient workup for a patient who has experienced a fall?

Inpatient Workup for Falls

A comprehensive inpatient fall workup should include mobility assessment, medication review, cognitive evaluation, orthostatic vital signs, and targeted laboratory testing to identify modifiable risk factors and reduce mortality and morbidity. 1, 2

Initial Assessment

• Three key screening questions:

  1. Have you fallen in the past year?
  2. Do you feel unsteady when standing or walking?
  3. Are you worried about falling?

  A positive response to any question indicates increased fall risk 1

• Functional mobility testing:

  • Timed Up and Go (TUG) test: Patient rises from chair, walks 3 meters, turns, returns to chair, sits down

    • 12 seconds indicates increased fall risk 1

  • 4-Stage Balance Test: Patient stands in progressively challenging positions for 10 seconds each
    • Inability to maintain tandem stand for 10 seconds indicates increased fall risk 1

Comprehensive Evaluation

Medical History

• Focus on risk factors using P-SCHEME mnemonic: 1
  • Pain (axial or lower extremity)
  • Shoes (suboptimal footwear)
  • Cognitive impairment
  • Hypotension (orthostatic or iatrogenic)
  • Eyesight (vision impairment)
  • Medications (centrally acting)
  • Environmental factors

Physical Examination

• Neurological assessment:

  • Evaluate for posterior circulation findings (dysarthria, dysmetria, dysphagia, sensory/motor deficits) 1
  • Check for Horner's syndrome 1
  • Assess for Parkinsonism features 3

• Cardiovascular assessment:

  • Orthostatic vital signs (measure BP/HR supine, then after standing 1 and 3 minutes)
  • Cardiac examination for arrhythmias

• Musculoskeletal assessment:

  • Joint range of motion
  • Muscle strength testing
  • Gait pattern evaluation

Laboratory and Diagnostic Testing

• Essential laboratory studies: 2

  • Complete blood count
  • Comprehensive metabolic panel
  • Vitamin D level
  • ECG
  • Consider Holter monitoring/event recorder for suspected syncope

• Additional testing based on clinical suspicion:

  • Neuroimaging for focal neurological findings
  • Bone density testing if osteoporosis suspected

Medication Review

• High-priority medications to evaluate: 2

  • Sedatives and hypnotics
  • Antipsychotics
  • Antidepressants
  • Antihypertensives
  • Diuretics
  • Narcotics

• Medication adjustment strategies:

  • Discontinue medications without immediate effect on symptom relief
  • Adjust timing and dosage of diuretics to reduce incontinence risk
  • Simplify medication regimens to improve adherence 2

Multidisciplinary Management

• Physical therapy consultation:

  • Evaluate need for assistive devices
  • Design tailored exercise program focusing on balance, strength, and gait 2

• Occupational therapy assessment:

  • Evaluate activities of daily living
  • Recommend adaptive equipment

• Specialty referrals as needed:

  • Geriatrics for comprehensive geriatric assessment
  • Neurology for movement disorders or neuropathy
  • Cardiology for syncope evaluation

Common Pitfalls to Avoid

1. Focusing only on the injury: The injury resulting from the fall should not be the sole focus; identify the underlying cause 4

2. Missing vestibular disorders: BPPV is common in elderly patients and frequently associated with falls 1

3. Overlooking patient perspective: Include patients in fall risk communication and prevention strategies 5

4. Inadequate documentation: Ensure thorough documentation of fall history and musculoskeletal examination 6

5. Failure to recognize department-specific risks: Fall rates and circumstances vary significantly between clinical departments (geriatrics > internal medicine > surgery) 7

By implementing this systematic approach to inpatient fall evaluation, clinicians can identify modifiable risk factors, develop targeted interventions, and ultimately reduce the morbidity and mortality associated with falls.